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Details of this error have been logged.Submission Success!Patient DetailsPatient First Name*Patient Last NamePatient Date of Birth*Patient Phone Number*Patient Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZip*Provider DetailsI hereby grant CAROLINA HOUSE Location: 176 Lassiter Homestead, Road, Durham, NC 27713 Phone: 919-864-1004 ; FAX: 877-275-7813Authorization for the FollowingTo Release Information To:To Exchange Information With:Name of Person/Provider*Relationship*Company*Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZip Code*Provider Phone*Provider EmailProvider FaxBy submitting and digitally signing this form, I hereby authorize CAROLINA HOUSE or agent, to disclose information contained in the medical and financial record of the patient identified above, which includes information that may be stored in a paper and/or other electronic format. However, such notes may contain information on general medical care; alcohol and drug abuse treatment; psychological and socialwork counseling; human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS), or AIDS related complex. Including communicable diseases or infections, sexually transmitted diseases, venereal diseases, tuberculosis and hepatitis; demographic information; and treatment received at other health care facilities. Disclosure shall be limited to the following specific information contained in my records and/or obtained during the course of my diagnosis and treatment.The following information is requested: (patient or legal guardian items to be released).*Psychiatric EvaluationLaboratory ReportsFinancial Account InformationHistory & PhysicalImmunization RecordsPractitioner OrdersMedication RecordsPractitioner Progress NotesTreatment/Individualized Service PlanDischarge SummaryDischarge InstructionsOtherThe purpose or need for disclosure is:*To Transfer Client CareFor Follow Up CareTo Inform FacilityReferral SourceLegal/Court SystemTo Aid in TreatmentFor Discharge PlanningTo Update Medical RecordsEmployerApplication for Provider CoveragePsychological ReportTo Aid in Financial Account ActivityOtherRecords to DiscloseI understand that the information in my health record may include information relating to sexually transmitted disease, immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services,and treatment for alcohol and drug abuse. State and federal law protect the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate).Alcohol, Drug or Substance Abuse Records*YesNoHIV Testing and Results*YesNoMental Health Records*YesNoDisclosure DetailsDisclosure Format (Paper/US Mail or Fax is default if not marked).This authorization is valid only if received within 60 days of being signed. This authorization will expire at the time of disclosure of requested information or on the following date (date cannot be more than 180 days after date signed below):Disclosure Expiration Date*Reminder: Date cannot be more than 180 days from the date below.Revocation of Authorization, RevocationI may revoke this authorization at any time. Revocations to this authorization must be presented in writing. Revocation will not apply to information disclosed prior to receiving a written revocation. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient, and may no longer be protected by federal and state privacy laws and regulations. I understand that CAROLINA HOUSE will not condition my treatment, payment, enrollment or eligibility for benefits on whether I provide this authorization. By submitting and digitally signing this form, I acknowledge I am aware of the confidential and/or privileged nature of the information being disclosed, and understand the benefits and/or disadvantage of disclosing such information. I hereby release CAROLINA HOUSE, its affiliates and its agent and representatives, (including collection agencies) from all legal liabilities that may result from the release of this information according to this request. I also expressly consent and authorize to be contacted by the phone number provided (cellular r residential) by any type of voice method and by auto-dialer technology for any permissible purpose.Acknowledgement*I UnderstandSignaturePatient or Authorized Representative Name*Today's Date*Relationship to Patient (if applicable)Signature*Draw your signature in the box below, then click the Confirm Signature button below the box.Clear SignatureConfirm Signature
